Provider Demographics
NPI:1255105623
Name:CHAMALOV, ILANA
Entity type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:CHAMALOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10218 64TH AVE APT 6X
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1566
Mailing Address - Country:US
Mailing Address - Phone:347-935-8058
Mailing Address - Fax:
Practice Address - Street 1:10218 64TH AVE APT 6X
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1566
Practice Address - Country:US
Practice Address - Phone:347-935-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist